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w , i . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` }} 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES ExPIRES 1 YEAR FROM GATE ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made torthe San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump { and the Rules and Regulatio s of the San Joaquin Local Health District. Job Address &i Subdivision Na/me Owner's Name Address // 1 Phone Contractor's Name License No. q� -2_1 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION L] SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial` U Open Bottom Manteca Dia. of Well Excavation J Domestic/Private Gravel Pack Tracy Dia. of Well Casing k Public Other. Delta Type of Casing Fj Irrigation Approx. E] Eastern Specifications f_1Cathodic,Protection Depth Depth,of Grout Seal ❑Geophysical Other ' �b Type—of-Grout Surface Seal Installed by Repair Work Done JJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') ,,-'TYPE OF SEPTIC WORK: NEW INSTALLATIONEP /ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) C Installation will serve: Residence _ Commercial Other ] G f Number of living units: _� Number of b drooms Lot size Z gl, + Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK F-1 Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. L] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest-: Well Foundation � ( Property Line DESTRUCTION ❑ LEACHING LINE J No. & Length of lines Tqtal length/size__ FILTER BED L] Distance to nearest: Well i Foundation Property Line SEEPAGE PITS f_1 -Depth Size Z-y J9 -Number SUMPS Distance to nearest: Well e i kl_Foundation Property Line DISPOSAL PONDS J k I hereby certify that I have prepared this application and thatthe_(wo e,o-ill-'be donih accor once-with-San Joaquin county ^� ordinances, state laws, and rules and regulations of the.San Joaquin Local Health District. Home owner or licensed agent's signature certifies the`.foi;lowing: "I certify that in the performance of the work for which this' permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." -Contractor'-s--hiring--or-sub=con tracting--s-tgrature certifies-the following:"•I certify-t-hat-in-the-performance-of-the-work-for which this permit is '-Ssued, I shall employ persons subject to workman's compensation laws of California." The applica st�11rl �,rinspectlo,s_ Complete dra ing-on reverse side. Signed X 'Title: Date: FO ARTMFNT USE ONLY i Application Accepted'.by Area µ Stk 466-6781 Additional Comments: Lodi 359-3621 Pit or Grout Inspection by Date J Manteca 823-7104 "} Final Inspection by Date� ❑ Tracy 835-6385 Applicant - Return all copies o: Environ ental Heal t Permit/Services 1 0I E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 . I